Condition
Calcific tendonitis
Calcific tendonitis is the formation of calcium deposits within one of the rotator cuff tendons. The condition often follows a self-limiting course over months to years, but can flare into severe sudden pain when the calcium deposit ruptures into the bursa.
Anatomy and pathology
What is calcific tendonitis
Calcific tendonitis is the abnormal deposition of calcium hydroxyapatite crystals in one of the rotator cuff tendons, a group of four tendons that hold the ball of the shoulder centred on the socket and provide the lifting and rotating motion of the arm. Calcific tendonitis most commonly occurs in the supraspinatus tendon. The deposit has the consistency of toothpaste or wet sand.
The condition usually progresses through several stages: a pre-calcific phase, a calcific phase where the deposit forms and matures, and a resorptive phase where the deposit softens and is broken down by the body. The resorptive phase is when the most severe pain occurs, often as the deposit ruptures into the bursa above the cuff.
The cause of the calcium deposition is not fully understood. It is more common in women than men, and most commonly affects people in their 30s, 40s, and 50s. Diabetes and thyroid disorders are weakly associated.
Symptoms
How calcific tendonitis presents
The presentation depends on the stage of the condition. Some patients have a slowly worsening shoulder ache that mimics a cuff tear or impingement. Others present in extreme, well-localised pain that has come on suddenly without any identifiable injury.
The acute resorptive flare is a very characteristic presentation. Patients often describe the worst shoulder pain they have ever had, with the arm held still by the side and significant difficulty moving the shoulder at all. The pain may be associated with mild redness, warmth, and a low-grade fever, which can mimic a septic joint and sometimes leads to emergency department presentations.
Diagnosis
How calcific tendonitis is diagnosed
Calcific tendonitis is usually diagnosed on x-rays, which show the calcium deposit clearly. The size, location, and density of the deposit can also help guide treatment, since softer deposits in the resorptive phase respond differently to treatment than dense deposits in the calcific phase.
- X-rays. Diagnostic. Show the calcium deposit, its size, and its location.
- Ultrasound or MRI. Useful to look for an associated cuff tear or bursitis, particularly when symptoms are out of proportion to what is visible on x-ray.
Treatment
Treatment options
Calcific tendonitis often resolves on its own as the body breaks down the deposit, but the process can take months and the symptoms can be very severe. Treatment is staged from non-operative measures to procedures.
- Anti-inflammatory medication and analgesia. A short course of an oral anti-inflammatory and stronger analgesia for the acute flare. Usually combined with sling support for comfort in the first few days.
- Physiotherapy. Useful once the acute pain has settled, to maintain motion and rotator-cuff strength.
- Subacromial corticosteroid injection. Effective for settling acute inflammation in the bursa.
- Barbotage (needling and lavage). An ultrasound-guided procedure where the calcium deposit is punctured with a needle and broken up so that the body can clear it. Effective for symptomatic deposits in the right phase.
- Extracorporeal shock wave therapy (ESWT). A non-invasive treatment that delivers focused acoustic waves to the deposit to encourage breakdown.
- Arthroscopic removal. Keyhole surgery to remove a persistent symptomatic deposit under direct vision. Reserved for deposits that have not responded to non-operative measures.
Recovery
What to expect after treatment
After non-operative treatment, the acute pain usually settles over days to weeks. Some residual ache and stiffness can persist for months while the deposit is fully resorbed and the tendon heals.
After barbotage or arthroscopic removal, recovery is similar to recovery from arthroscopic subacromial decompression. A sling is worn for comfort for a few days only. Active movement starts straight away, with strengthening from around four to six weeks. Most patients return to office work within a week or two.
FAQ
Frequently asked questions
- How is calcific tendonitis diagnosed?
- Calcific tendonitis is usually diagnosed on plain x-rays, which show the calcium deposit clearly within the rotator cuff tendon. The size, location, and density of the deposit help guide treatment. Ultrasound or MRI can be added to look for an associated cuff tear or bursitis if symptoms are out of proportion to the x-ray findings.
- Why does calcific tendonitis hurt so much?
- The most severe pain occurs in the resorptive phase, when the body is breaking down the calcium deposit and the deposit can rupture into the bursa above the cuff. This causes intense inflammation, often with redness and warmth around the shoulder, and is sometimes mistaken for a septic joint or even a heart problem.
- Will calcific tendonitis go away on its own?
- Yes, in most cases. The body eventually breaks down the deposit through the resorptive phase. The challenge is that the process can take months and the symptoms can be severe. Treatment is aimed at managing the pain and, in resistant cases, accelerating the breakdown of the deposit.
- What is barbotage?
- Barbotage is an ultrasound-guided procedure in which the calcium deposit is punctured with a needle and broken up so the body can clear it. It is effective for symptomatic deposits in the right phase. Most patients tolerate the procedure well, with significant pain relief in the days that follow.
- Is surgery needed for calcific tendonitis?
- Rarely. Most cases settle with non-operative measures including anti-inflammatories, corticosteroid injections, barbotage, and shock wave therapy. Arthroscopic removal is reserved for persistent symptomatic deposits that have not responded to these measures.
Severe sudden shoulder pain?
Book an appointment with Dr Piper
Consultations at Lakeview Private Hospital, Norwest. Bring a referral and any imaging you have.